Volunteer Application

Full Name:
Street Address:
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Flordia Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Phone(Home):
Phone(Work):
Email Address:
May we contact you at work:	Yes No
Educational background:
Occupation
Describe your hobbies, skills and interests:
Do you have transportation constraints:	Yes No
Do you have physical limitations:	Yes No
In what capacity are you interested in volunteering?
Childcare assistant in FACTS Nursery Comparion for HIV+ adults Fundraising and special events Clerical work Harm reduction program assistant Other (please describe below)
Do you speak Spanish:	Yes No
When are you available: